LEWIS'S MEDICAL-SURGICAL NURSING
ASSESSMENT AND MANAGEMENT OF
CLINICAL PROBLEMS, SINGLE VOLUME
12TH EDITION
• AUTHOR(S)MARIANN M. HARDING;
JEFFREY KWONG; DEBRA HAGLER;
COURTNEY REINISCH
TEST BANK
1
Reference: Ch. 1 — Professional Nursing — Professional Nursing
Practice
Stem: A 68-year-old post-op patient has new onset confusion
and a respiratory rate of 30/min. The nurse notes the family
wants to take the patient home “for comfort.” Using
professional nursing standards and scope, what is the nurse’s
priority action?
A. Honor the family’s request and discharge the patient to
home with comfort measures.
,B. Conduct a focused assessment and notify the surgeon
immediately.
C. Explain that confusion is common and document the family’s
request.
D. Offer PRN analgesia and ask the family to stay overnight.
Correct answer: B
Rationale — Correct (B): A focused assessment and immediate
notification align with the nurse’s professional responsibility to
identify and escalate acute changes in status (tachypnea and
new confusion suggest hypoxia or delirium). Lewis emphasizes
scope of practice and standards requiring timely assessment
and communication with the interprofessional team for patient
safety. This action prioritizes patient stability and appropriate
escalation rather than yielding to non-clinical requests. Clinical
judgment: recognize change → analyze severity → plan to
escalate.
Rationale — Incorrect:
A. Discharging an unstable post-op patient is unsafe and outside
the nurse’s professional obligation.
C. Dismissing signs as “common” and only documenting delays
necessary intervention.
D. PRN analgesia may be appropriate for pain but does not
address potential respiratory compromise or new confusion.
Teaching point: New confusion + tachypnea requires immediate
assessment and team notification.
Citation: Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C.
(2023). Lewis’s Medical-Surgical Nursing (12th Ed.). Ch. 1.
,2
Reference: Ch. 1 — Professional Nursing — Definitions of
Nursing
Stem: A nurse working on a med-surg unit is asked to explain to
a new graduate how nursing’s view of humanity shapes care
plans. Which statement best reflects nursing’s view when
creating person-centered goals?
A. Focus solely on physiologic measures because they are
objective.
B. Consider physical, psychosocial, cultural, and spiritual needs
in planning.
C. Prioritize family wishes above patient preferences.
D. Use standardized orders for every patient to ensure
consistency.
Correct answer: B
Rationale — Correct (B): Lewis defines nursing as holistic,
viewing the patient as a whole person whose care must address
physical, psychosocial, cultural, and spiritual domains. Person-
centered goals reflect that view and support individualized care
plans. Clinical judgment integrates patient values with best
evidence to create achievable outcomes.
Rationale — Incorrect:
A. Physiologic measures are important but insufficient alone for
comprehensive nursing care.
C. Family wishes are important but should not override the
, patient’s own values and autonomy.
D. Standardized orders may aid safety but must be
individualized to the patient’s needs.
Teaching point: Nursing care plans must address physical,
psychosocial, cultural, and spiritual needs.
Citation: Harding et al. (2023). Lewis’s Medical-Surgical Nursing.
Ch. 1.
3
Reference: Ch. 1 — Professional Nursing — Scope of Nursing
Practice
Stem: A licensed practical nurse (LPN) asks the RN to delegate a
new admission assessment for a stable patient who is
ambulatory and postoperative day 2. Based on scope and
delegation principles, the RN should:
A. Assign the entire admission assessment and initial care
planning to the LPN.
B. Complete the initial comprehensive assessment and delegate
routine tasks to the LPN.
C. Tell the LPN to perform the comprehensive assessment
without oversight.
D. Refuse all delegation and complete every task personally.
Correct answer: B
Rationale — Correct (B): Lewis and delegation frameworks
require the RN to perform initial comprehensive assessments
and critical clinical decision-making; stable, routine tasks may
ASSESSMENT AND MANAGEMENT OF
CLINICAL PROBLEMS, SINGLE VOLUME
12TH EDITION
• AUTHOR(S)MARIANN M. HARDING;
JEFFREY KWONG; DEBRA HAGLER;
COURTNEY REINISCH
TEST BANK
1
Reference: Ch. 1 — Professional Nursing — Professional Nursing
Practice
Stem: A 68-year-old post-op patient has new onset confusion
and a respiratory rate of 30/min. The nurse notes the family
wants to take the patient home “for comfort.” Using
professional nursing standards and scope, what is the nurse’s
priority action?
A. Honor the family’s request and discharge the patient to
home with comfort measures.
,B. Conduct a focused assessment and notify the surgeon
immediately.
C. Explain that confusion is common and document the family’s
request.
D. Offer PRN analgesia and ask the family to stay overnight.
Correct answer: B
Rationale — Correct (B): A focused assessment and immediate
notification align with the nurse’s professional responsibility to
identify and escalate acute changes in status (tachypnea and
new confusion suggest hypoxia or delirium). Lewis emphasizes
scope of practice and standards requiring timely assessment
and communication with the interprofessional team for patient
safety. This action prioritizes patient stability and appropriate
escalation rather than yielding to non-clinical requests. Clinical
judgment: recognize change → analyze severity → plan to
escalate.
Rationale — Incorrect:
A. Discharging an unstable post-op patient is unsafe and outside
the nurse’s professional obligation.
C. Dismissing signs as “common” and only documenting delays
necessary intervention.
D. PRN analgesia may be appropriate for pain but does not
address potential respiratory compromise or new confusion.
Teaching point: New confusion + tachypnea requires immediate
assessment and team notification.
Citation: Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C.
(2023). Lewis’s Medical-Surgical Nursing (12th Ed.). Ch. 1.
,2
Reference: Ch. 1 — Professional Nursing — Definitions of
Nursing
Stem: A nurse working on a med-surg unit is asked to explain to
a new graduate how nursing’s view of humanity shapes care
plans. Which statement best reflects nursing’s view when
creating person-centered goals?
A. Focus solely on physiologic measures because they are
objective.
B. Consider physical, psychosocial, cultural, and spiritual needs
in planning.
C. Prioritize family wishes above patient preferences.
D. Use standardized orders for every patient to ensure
consistency.
Correct answer: B
Rationale — Correct (B): Lewis defines nursing as holistic,
viewing the patient as a whole person whose care must address
physical, psychosocial, cultural, and spiritual domains. Person-
centered goals reflect that view and support individualized care
plans. Clinical judgment integrates patient values with best
evidence to create achievable outcomes.
Rationale — Incorrect:
A. Physiologic measures are important but insufficient alone for
comprehensive nursing care.
C. Family wishes are important but should not override the
, patient’s own values and autonomy.
D. Standardized orders may aid safety but must be
individualized to the patient’s needs.
Teaching point: Nursing care plans must address physical,
psychosocial, cultural, and spiritual needs.
Citation: Harding et al. (2023). Lewis’s Medical-Surgical Nursing.
Ch. 1.
3
Reference: Ch. 1 — Professional Nursing — Scope of Nursing
Practice
Stem: A licensed practical nurse (LPN) asks the RN to delegate a
new admission assessment for a stable patient who is
ambulatory and postoperative day 2. Based on scope and
delegation principles, the RN should:
A. Assign the entire admission assessment and initial care
planning to the LPN.
B. Complete the initial comprehensive assessment and delegate
routine tasks to the LPN.
C. Tell the LPN to perform the comprehensive assessment
without oversight.
D. Refuse all delegation and complete every task personally.
Correct answer: B
Rationale — Correct (B): Lewis and delegation frameworks
require the RN to perform initial comprehensive assessments
and critical clinical decision-making; stable, routine tasks may
